IHCP bulletin INDIANA HEALTH COVERAGE PROGRAMS BT201307 MARCH 19, 2013

New Indiana Medicaid Pharmacy Benefit Manager targeted to be implemented in late May 2013 As previously announced in bulletin BT201237, Catamaran Corporation will serve as the new Pharmacy Benefit Manager

(PBM) and pharmacy claims processor for the Indiana Health Coverage Programs (IHCP). This change is targeted for an

effective date in late May 2013. This bulletin provides specific information about the roles and responsibilities of

Catamaran and describes any changes that will affect providers.

The information in this bulletin applies to all pharmacy services rendered under the fee-for-service and managed care

delivery systems. The provisions in this bulletin also apply to the Healthy Indiana Plan (HIP). The exact implementation

date will be published in a follow-up bulletin at least 30 days prior to the actual transition. It is important that you, as an

IHCP provider, share the technical components in this document with your software and/or switch vendor to ensure all

pharmacy claims are routed appropriately to Catamaran beginning on the implementation date.

Instruction for submission—point-of-sale claims, batch claims, paper claims, reversals, and adjustments

The PBM transition does not change any existing coverage policies or rules that govern IHCP pharmacy benefits. For

example, claim filing limits, pricing, Preferred Drug List (PDL) content, utilization and step therapy edits, and quantity

limits are not changing as a result of this transition.

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IHCP bulletin BT201307 MARCH 19, 2013

Point-of-sale claims

HP (the current pharmacy claims processor) will continue to accept point-of-sale (POS) claims until 6 p.m. Eastern

Standard Time (EST) on the day prior to the implementation date. At 6 p.m. the pharmacy claims processing system will

be shut down for a period of time not to exceed 12 consecutive hours. The scheduled downtime is necessary to allow

the transfer of historical claims data from HP to Catamaran. During this downtime, pharmacy providers should use the

Automated Voice Response (AVR) system, an Omni device, or Web interChange to determine member eligibility.

Prescriptions should continue to be dispensed during the downtime. For payment, providers may wait until POS service

is restored to submit a claim electronically or may submit the claim via paper.

All pharmacy claims should continue to be submitted via the National Council for Prescription Drug Programs (NCPDP)

version D.0. A copy of the NCPDP Version D.0 Transaction Payer Sheet issued by Catamaran will be available to

providers under the Pharmacy Services link on indianamedicaid.com beginning on the implementation date. Prior to that

date, the NCPDP D.0 and 1.2 Transaction Payer Sheet V2.0, currently located on the IHCP Companion Guides page of

indianamedicaid.com should be used.

Please note the bank identification number (BIN) and processor control number (PCN) in Table 1. When the pharmacy

claims processing system is operational (no later than 6 a.m. EST on the implementation date), providers should direct

pharmacy claims to the BIN/PCN combination shown in the following table.

Any POS claim submitted to HP after 6 p.m. EST on the day prior to the implementation date, will be rejected with

NCPDP reject code 1 − Invalid BIN Number along with the message, Please submit to BIN 001553 PCN INM.

Electronic batch claims

HP will continue to accept electronic batch pharmacy claims until 6 p.m. EST on the day prior to the implementation

date. After that time, electronic batch pharmacy claims will no longer be accepted by the IHCP for processing.

Catamaran will not be processing electronic batch claims.

Paper claims

Providers should continue to submit paper claims on the existing claim forms. As of the implementation date, the

appropriate forms will be accessible under the Pharmacy Services link on indianamedicaid.com. Beginning on the

implementation date, paper claims must be mailed to Catamaran at the following address:

Catamaran Manual Claims PO Box 5206

Lisle, IL 60532-5206

For a period of 30 calendar days from the implementation date, any paper claims erroneously directed to HP will be

forwarded to Catamaran. Paper claims received by HP after 30 calendar days following the implementation date, will be

returned to the provider for appropriate routing.

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BIN 001553

PCN INM

Group Not required

Table 1 − BIN/PCN combination effective on new PBM implementation date

IHCP bulletin BT201307 MARCH 19, 2013

Reversals

Beginning on the implementation date, Catamaran will be processing all reversals and rebills for pharmacy claims,

including those originally adjudicated prior to the implementation date. It is important to note that pharmacies must work

with their software vendors to ensure that all electronic reversal (B2) and rebill (B3) transactions are routed to

Catamaran for processing. For reversals or rebills that cannot be processed electronically, please contact the

Catamaran Clinical/Technical Help Desk (toll free) at 1-855-577-6317.

Enhanced coordination of benefits

Catamaran will use the same third-party liability (TPL) information that

HP uses today to identify other potential payers. In addition, Catamaran

will use an enhanced coordination of benefits (eCOB) process to assist in

the identification of other potential third-party payer resources.

If the eCOB process identifies that the member has TPL, the POS claim

will reject with the NCPDP code “41,” along with a message outlining the

member’s TPL information. Pharmacies may resubmit the claims with the

appropriate NCPDP value in the “Other Coverage Code" field along with

the required COB segment information to override the TPL edit for payment consideration from IHCP.

The following example shows a short message that indicates additional insurance is present; ADDINS is displayed,

followed by the BIN (BN), PCN (PN), Group (GP), Cardholder ID (ID), Person Code (PC), and Helpdesk Phone (PH) for

the alternate insurance processor.

Figure 1 − Example of message indicating additional insurance is present

Prospective Drug Utilization Review

Catamaran will use Medi-Span’s drug file not only for adjudication of pharmacy claims, but as a source of Prospective

Drug Utilization Review (pro-DUR) criteria as well. Because the primary file used by HP has been First DataBank,

providers may notice subtle differences in pro-DUR alerts. However, all pro-DUR messaging and “hard alerts” (meaning,

override of the alert requires prior authorization [PA]) will remain the same.

ADDINS:1;BN:000999;PN: ;GP:A123

55599900000;ID:ABC123456789;PC:2;PH:

8005551212;&

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Please Note: The date of adjudication is the date the claim

was submitted for processing. The date of adjudication

(submission) is not necessarily the date of service.

IHCP bulletin BT201307 MARCH 19, 2013

Retrospective Drug Utilization Review

The Retrospective Drug Utilization Review (retro-DUR) program will transition from Xerox to Catamaran. Catamaran will

coordinate and manage the retro-DUR process, which includes contacting providers through correspondence to provide

information pertaining to DUR Board interventions. Catamaran will also create articles pertaining to Board-approved

retro-DUR topics for incorporation into DUR Board newsletters.

Claim appeal and administrative review procedures

Claim appeal and administrative review procedures are outlined in Chapter 10 – Claims Processing Procedures, Section

6 of the IHCP Provider Manual. Beginning on the implementation date, pharmacy providers must direct any requests for

administrative review to Catamaran at the following address:

Catamaran PO Box 44085

Indianapolis, IN 46244-0085

As a courtesy to providers, HP and Xerox will forward any misdirected claim appeal and administrative review

correspondence to Catamaran for a period of 30 calendar days after the implementation date. After 30 calendar days

following the implementation date, correspondence received by HP or Xerox will be returned to the provider for

appropriate routing.

Payment and financial information

As of the implementation date, Catamaran will be responsible for issuing

pharmacy claims payment electronic Remittance Advice (RA) in the Health

Insurance Portability and Accountability Act (HIPAA) standard 835 format. The

IHCP is subject to the same rules and regulations as all other payers. As such,

Catamaran is required to report payments made to providers annually through the

1099 reporting process. Providers do not need to submit any new information to

facilitate this process.

Rate setting

Catamaran will manage all aspects of the administration of the Indiana Medicaid

State Maximum Allowable Cost (MAC) Program for Federal Legend Drugs, Blood

Factors, and Over-the-Counter (OTC) Drug Formularies. Catamaran will be

responsible for the development and ongoing maintenance of all such rates, as

well as for the day-to-day administration of the State MAC Program.

Other pharmacy-related program information

Call center

Catamaran will host a call center that will respond to technical and clinical pharmacy-related inquiries, such as PA

requests and questions related to pharmacy claim audits. Member calls related to pharmacy benefits will also be

addressed by Catamaran. The Catamaran Clinical/Technical Help Desk will be functional on the implementation date,

and will be open 24 hours a day, seven days a week. Calls related to provider enrollment, physician-administered drugs,

Web interChange, and all other nonpharmacy calls will continue to be handled by HP. The Catamaran Clinical/Technical

Help Desk number is (toll free) 1-855-577-6317. This number will also be published under the Pharmacy Services link

on indianamedicaid.com.

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IHCP bulletin BT201307 MARCH 19, 2013

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Preferred Drug List and Over-the-Counter Drug Formularies

The PDL and OTC Drug Formularies are not changing as a result of this transition. All existing PDL limits and requirements

remain in effect. As of the implementation date, a copy of the PDL and OTC Drug Formularies will be available under the

Pharmacy Services link on indianamedicaid.com. Beginning on the implementation date, pharmacies and prescribers should

contact Catamaran with any questions related to the PDL or OTC Drug Formularies. The Catamaran Clinical/Technical Help

Desk number is (toll free) 1-855-577-6317. The number will also be published under the Pharmacy Services link on

indianamedicaid.com.

Pharmacy-related prior authorization

Criteria used in PA determinations will not change as a result of the transition. Existing PAs, including start and end dates,

will be transferred to Catamaran; providers need not take any action regarding existing PAs. Pharmacy providers and

prescribing practitioners should direct any PA-related questions or requests to Catamaran beginning on the implementation

date. The Catamaran Clinical/Technical Help Desk number is (toll free) 1-855-577-6317. The number will also be published

under the Pharmacy Services link on indianamedicaid.com.

E-Prescribing

Catamaran, through its existing affiliations with e-prescribing switching vendors, Surescripts and Allscripts, will enhance

prescriber’s existing e-prescribing capabilities by providing access to member eligibility, formulary, and medication history

information.

Pharmacy audit

All pharmacy auditing responsibilities will be transitioned from HMS (formerly PrudentRx) to Catamaran. The Catamaran

audit programs consist of the following modules for auditing the IHCP pharmacy benefit program:

Real-Time/Telephone Audits

Desktop Audits or Investigational Audits

Onsite Reviews (OSRs)

Focused Investigative Audits (FIAs)

Website

Effective on the implementation date, indianapbm.com will no longer be a functioning website. All information previously on

indianapbm.com, including current reference forms and materials that continue to be relevant, will be consolidated under the

Pharmacy Services link on indianamedicaid.com, including the following:

Current and archived PDLs

Current and archived OTC drug formularies

All pharmacy-related PA forms

Pharmacy-related frequently asked questions (FAQs) for

providers and members

Therapeutic Committee meeting agendas and minutes

DUR Board meeting agendas and minutes

It is important to note that with the transition to the

new PBM, some of the commonly referenced web

pages will be found in new locations. All web pages

will continue to be readily accessible, however,

through the Pharmacy Services quick link on the

provider home page of indianamedicaid.com. If you

have set bookmarks for these resources, new

bookmarks will need to be established.

IHCP bulletin BT201307 MARCH 19, 2013

If you have questions about this publication, please

contact Customer Assistance at (317) 655-3240 in the

Indianapolis local area or toll-free at 1-800-577-1278.

QUESTIONS?

If you need additional copies of this publication, please

download them from indianamedicaid.com. To receive

email notices of future IHCP publications, subscribe to

IHCP Email Notifications.

COPIES OF THIS PUBLICATION

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Drug Efficacy Study Implementation (DESI) drug list

Indiana Medicaid State MAC list

Catamaran’s web pages containing Indiana Medicaid pharmacy benefit information will be accessible under the Pharmacy

Services link on indianamedicaid.com beginning on the implementation date. Chapter 9 – IHCP Pharmacy Services Benefit

of the IHCP Provider Manual will continue to outline pharmacy policy and procedures, with updates to reflect the PBM

transition, and be accessible on the Manuals page of indianamedicaid.com.